1. What is your age? 1. What is your age? 18-24 25-34 35-44 45-54 55-60 60+

2. Are you currently wearing...? (Please check all that apply) 2. Are you currently wearing...? (Please check all that apply) Eyeglasses Reading Glasses Bifocals Soft Contact Lenses Soft Toric Contact Lenses Gas Permeable Rigid Contact Lenses Hard Contact Lenses None of the above Other

3. What best describes your reason for corrective lenses? (Please check all that apply) 3. What best describes your reason for corrective lenses? (Please check all that apply) I’m nearsighted (Myopic) I’m farsighted (Hyperopic) I have difficulty reading Overall, my vision is blurry

4. Have you been told you have...? (Please check all that apply) 4. Have you been told you have...? (Please check all that apply) Astigmatism Dry Eyes Keratoconus Macular Degeneration Glaucoma Cataracts Herpes simplex or Herpes zoster (shingles) involving the eye area Any autoimmune diseases (e.g. lupus, rheumatoid arthritis) immunodeficiency states (e.g. HIV) or diabetes

5. Have you had a stable prescription or has your vision been stable for at least a year? 5. Have you had a stable prescription or has your vision been stable for at least a year? Yes No

6. Do you know your prescription? 6. Do you know your prescription? +5 to 0 0 to -5 -5 to -10 -10 or higher I don’t know

7. Are you currently nursing or pregnant? 7. Are you currently nursing or pregnant? Yes No

8. What are your primary concerns with LASIK? (Please check all that apply) 8. What are your primary concerns with LASIK? (Please check all that apply) Affordability Safety Experience level of doctor(s) Recovery time

9. Have you ever had an eye injury or eye surgery? 9. Have you ever had an eye injury or eye surgery? Yes No

10. Would you like to be contacted to schedule a LASIK screening? 10. Would you like to be contacted to schedule a LASIK screening? Yes Not right now – I’m still shopping around I already have an appointment

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